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Evaluation of a psychological treatment programme for climacteric women
Maturitus, 9 (1987) 41-48
41
Elsevier MAT 00426
Evaluation of a psychological treatment programme f or climacteric women J.G. Greene 1 and D.M. Hart 2 ’Department of Clinical Psychologv, Gartnavel Royal Hospital, and ’ Department of Gynaecology, Stobhill General Hospita1 Glasgow, U.K.
(Received 5 March 1986; version received 9 June 1986; accepted 10 December 1986)
A psychological assessment and treatment programme designed for a group of climacteric women with severe and varied psychological complaints and symptoms is described and evaluated. Ah the women were currently experiencing stressful psychosocial difficulties within their life situation. The treatment programme comprised an educational, a counselling and a behavioural component. By the end of the sixth session of therapy, most women showed a significant improvement in their main complaint, accompanied by improvements in general symptoms and personal adjustment. Two-thirds considered that they had benefited substantially from treatment. The outcome of the treatment was considered to be encouraging in what might otherwise be considered a potentially unresponsive group of women.
(Key words: Behaviour therapy; Counselling; Menopause; Psychotherapy)
Introduction
Many women attending menopause clinics for treatment of vasomotor symptoms and other climacteric problems also present with a variety of psychological symptoms and complaints. Hormone replacement therapy (HRT) is generally effective in bringing about relief of vasomotor symptoms, frequently accompanied by a feeling of general well-being [l] and the alleviation of psychological symptoms [2,3]. There remains, however, a group of women in whom HRT relieves the vasomotor symptoms, but has little effect on the other complaints. These women may require and benefit from more psychologically based treatments. This paper describes an assessment and treatment programme for such a group of women referred to a department of clinical psychology from a menopause clinic and evaluates the treatment outcome. Correspondence to: Dr. J.G. Greene, Department of Clinical Psychology, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G120XH, Scotland, U.K.
0378-5122/87/%03.50 0 1987 Elsevier Scientific Publishers Ireland, Ltd.
42
Subjects and methods
Subjects These were 24 climacteric women, who were admitted successively into tl treatment programme. Al1 were currently attending a menopause clinic to whic they had been referred for treatment of vasomotor symptoms. Five women we peri-menopausal, (last menstruation between 3 and 12 mth previously, and 19 we post-menopausal (no menstruation within the past year). Hormonal treatment hz relieved vasomotor symptoms in these women to such an extent that none was ar longer greatly bothered by them. However, they were referred to a psychologi because of persistent symptoms and complaints thought to be of psychogenic origi The onset of these complaints had occurred in al1 cases after the age of 40 durit the climacteric years, al1 of the subjects dating the onset to within 2 yr of referr; Assessment At the first appointment, the details and history of the main presenting cor plaint and information about personal and family circumstances as wel1 as al ongoing or long-standing sources of stress or worry were obtained by means of semi-structured interview. This was akin to a standard psychological interview. Li events of onset within the previous year were elicited using the List of Threatenil Life Experiences [4], this being a list of the 12 event categories which account for t great majority of distressing life events. In order to assess the outcome, the main presenting symptom was quantified 1 having the women rate how severe or disturbing it was by means of a lO-cm visu analogue scale [5], the end-points being labelled ‘not at all’ and ‘extremely’. T results were supplemented by the scores recorded on two other scales. One of the was the 18-item Climacteric Symptom Rating Scale developed by the author [ This yields 2 separate summed measures, one of 11 psychological symptoms (cryi spells, attacks of panic, worrying needlessly, etc.) and the other of 7 soma symptoms (rheumatic pains, dizzy spells, etc.) commonly reported by climacte women. The other was the IHF Index of Subjective Adaptation. This measures woman’s satisfaction with her daily life, health and future prospects. It was US because it seemed appropriate to some of the concerns these women voiced and 1: been shown to be a sensitive measure of climacteric response [7]. At the end of the first interview a case formulation was arrived at and tl formed the basis of the treatment approach for subsequent sessions. Al1 assessme and treatment was carried out by a clinical psychologist. Results
Main presenting complaints These were elicited in response to an open-ended question as to what constitui the main problem. A breakdown is given in Table 1; this does not exclude otl complaints, but indicates those spontaneously reported by the women as the mc
43 TABLE PATIENT
1 CHARACTERISTICS
Numbers treated Mean age Marital status Married Widowed Single Presenting complaint Anxiety/agitation Depressed/lethargic Psychosomatic symptom Sexual dysfunction Symptom rating scale Psychological (norm) Somatic (norm) Subjective adaptation Index (norm) Long-standing problems Husband’s illness Marital discord Children Elderly parents Recent life events Deaths Serious family illness Serious family discord
24 49 (range 42-55) 21 2 1 13 5 3 3 22.5 (11.8) 9.3 ( 4.9) 29.7 (18.3) 5 4 4 3 8 3 3
distressing. For example, in line with the findings of Sarrel and Whitehead [8] sexual complaints were common, but for the most part did not constitute serious sexual dysfunction. Only 3 women saw them as the major problem for which they wanted help and in al1 3 this entailed loss of desire. They were seen by the other women as less significant, or relatively so, in comparison with other complaints. Anxiety complaints consisted of a rnixture of generalised anxiety, transient panic attacks and situational phobias, most of which had an agoraphobic element. Depressive complaints consisted mainly of loss of energy and interest, and were reactive in nature, rather than endogenous. Psychosomatic symptoms included one case of recurrent chest pains, one of low back pain and one of recurring headaches. Eleven women were receiving tranquillisers from their genera1 practitioner, without much symptomatic relief, but only 2 had a history of psychiatrie treatment. It is important to reiterate that in al1 these women the onset of the presenting complaint had occurred during the climacteric years. These complaints were taken as the primary treatment targets and the main criteria for evaluating outcome. Climacteric
symptom
rating scale
As can be seen from Table 1, the mean scores for both psychological and somatic symptoms were higher than those in a genera1 population of Scottish climacteric women [9], indicating widespread genera1 symptoms.
44
Subjective adaptation
Compared with that in a genera1 population of Swiss menopausal women [7] this score was also high, indicating overall poor adaptation and dissatisfaction with mid-life status. Both this and the symptom scale were later used to assess the general outcome. Ongoing and long-standing problems
These were fairly common, and a total of 15 women had problems of this type, al1 associated with family members, which had been ongoing for some years prior to referral. One woman had 2 problems which fell into this category. A breakdown of these is shown in Table 1. In 3 cases the husband’s illness prevented him from working, thereby causing secondary financial worries. In 2 of the cases of marital discord, the husband’s alcoholism was playing a significant part. The problems connected with children comprised 2 where there was a chronic medical condition and 2 where there was marked social discord with the parents. In the case of elderly parents, the problems involved either a physical or mental disability, necessitating their being cared for by the family. Life events of recent onset
In all, 10 women reported one major, threatening life event occurring within the year prior to referral to the menopause clinic and a further 2 reported two such events. The 3 categories into which these 14 events fa11 are shown in Table 1. The deaths and ilhress had occurred mostly in the older generation, which is consistent with what was found in a general population of climacteric women [9], but the serieus family problems involved children in two cases. It should be noted that these were not the same as long-standing problems in that they were of recent onset and their impact is therefore considered to be quite different [lol. In general, from the symptomatic point of view, this was a fairly disturbed group of women, each of whom had at least one long-standing family problem or had experienced a recent stressful life event. Treatment programme
The broad treatment rationale was that the symptoms and complaints reported by these women were, in part at least, an expression of or a reaction to their current psychosocial problems. However, many of the problems had begun before the climacteric, although the symptoms and complaints had had their onset only during that time. The aetiological model adopted was that, during the climacteric, women become more vulnerable to the effects of psychosocial difficulties with which they might have been better able to cape at an earlier age. This model was based on the findings of a previous study in which it was found that climacteric women were less
45
able than pre-climacteric women to cape with adverse life events [9]. In this model, which is more fully described elsewhere [ll], vulnerability is considered to be both physical and psychological in nature, giving rise to both types of symptoms. This model shaped the treatment programme which had grown out of the therapist’s experience over a number of years in assessing and treating climacteric women with psychological problems. The therapy incorporates many of the standard and established methods of psychological treatment, modified or adapted to the particular needs of the climacteric woman. It is a pragmatic approach and has 3 major components, i.e., an educational, a counselling and a behavioural component. Educational
component
This component was aimed at giving women some understanding of the role played by psychosocial factors in their condition. Many tended to attribute al1 their symptoms to the menopause and were perplexed by the fact that although HRT had greatly helped their vasomotor symptoms, it had not relieved them of the others. In effect, the model referred to above was explained to them in the context of their own particular problems. This was found to be a necessary stage before proceeding further. Counselling
component
This consisted of discussing and advising women about their current problems and concerns. It included the exploration of feelings and attitudes, particularly those of women with low subjective adaptation. Where appropriate, bereavement counselling was used. This component is not a psychotherapeutic procedure as such, but more of a problem-solving exercise aimed at working out solutions and developing coping skills [12]. Behavioural
component
The object here was symptomatic treatment using standard behavioural techniques [13] such as anxiety management, desensitisation for phobic problems, and cognitive therapy for depressive symptoms. These included the use of relaxation tapes, diaries and home exercises as necessary. After the initial assessment women were seen at 3-4 week intervals for between 45-60 min. In practice, each session included elements of al1 3 components although, as indicated above, the educational aspect tended to be dealt with in the earlier sessions. Outcome of treatment
To evaluate the outcome, al1 the women were assessed at the end of the sixth session of treatment. Evaluation was carried out at this point in order to standardise the amount of treatment provided and because experience had shown that if progress had not been made with this type of treatment by this time, a satisfactory
46 TABLE
11
MEAN
SCORES
ON OUTCOME
MEASURES
BEFORE
AND AFTER
Means Pre
Post
Differente
8.6 22.5 9.3 29.7
4.1 14.2 6.7 21.1
4.5 8.3 2.6 8.6
TREATMENT t
P
5.92 3.32 2.10 2.50
< < < <
+SE Main presenting complaint Psychological symptoms Somatic symptoms Subjective adaptation r = paired
f f i: f
0.76 2.50 1.24 3.44
0.001 0.01 0.05 0.02
t-test value
outcome was unlikely. Nevertheless, several women continued to be seen beyond this point. Al1 the women again rated their main presenting symptom on the visual analogue scale. They also completed the Symptom Rating Scale and the Index of Subjective Adaptation and made a rating of their overall improvement over the treatment period. The results of this re-assessment are shown in Table 11. The results were analysed by the paired t-test. It can be seen that there was a highly significant decrease in the mean severity rating of the main complaint. There was also a significant reduction in general symptoms, especially psychological symptoms, and an improvement in subjective adaptation. In the overall improvement rating, 7 women rated themselves as considerably improved, 9 as much improved, 4 as moderately to slightly improved, 3 as unchanged and 1 as worse. In all, therefore, some two-thirds of the women thought that they had benefited substantially from treatment. There was, however, clear evidente that the response depended on the nature of the main complaint. Those with anxiety as a major element in their condition improved most, followed by those with depressive complaints. Women with psychosomatic complaints or loss of libido as the main presenting complaint showed little or no response to treatment. Of the 3 women with loss of sexual desire as a main complaint, 1 showed a slight improvement while 2 remained unchanged. In the case of the 3 with psychosomatic symptoms, 1 showed moderate improvement. 1 remained unchanged and 1 became worse over the treatment period. It is noteworthy (Table 11) that somatic symptoms showed the least statistically significant improvement.
Discussion
The psychological treatment package provided to this group of fairly disturbed climacteric women seems to have been reasonably successful in alleviating the main complaint in most cases. This improvement was accompanied by a reduction in general symptoms and, for some, it also seems to have resulted in their feeling less dissatisfied with their mid-life state. Not all the women showed the same degree of improvement, since certain complaints, notably psychosomatic and sexual ones,
47
were less responsive to therapy. However, this is not an unusual finding in regard to these latter complaints, which are notoriously resistant to psychotherapeutic approaches [14]. In the present study it was felt that the greater improvement in complaints with an anxiety or depressive element was due to the fact that these are also more amenable to a behavioural approach. This is not to say that the educational and counselling components did not contribute to the outcome. If it is accepted that psychosocial problems play a part in the aetiology of the complaints suffered by such women, then attaining insight into and a balanced perspective on these problems is a necessary first step towards remedying the symptomatic effects. Nevertheless, despite this insight, symptoms may sometimes persist and require to be treated by more direct behavioural or possibly pharmacological means. The weakness of an evaluative study of this kind is that, in the absente of a control group, it is not possible to state categorically the extent to which an improvement is a function of therapy rather than of other factors-although it is difficult to see how it would be possible to contrive a control group that could provide a convincing answer to that question. What can be said is that al1 the women had experienced persistent psychological complaints extending over a period of time prior to treatment and that none had shown the characteristic improvement in mental well-being associated with HRT and the relief of vasomotor symptoms. Nor had any shown much response to minor tranquillisers. Furthermore, it was the therapist’s observation over the treatment period that women who benefited were responding actively to the different treatment components in the anticipated way. Finally, the efficacy of such treatments, both short and long-term, has been repeatedly demonstrated with other types of patients [14]. Perhaps, therefore, it should come as no surprise that a generally satisfactory outcome should be achieved using what are in fact wel1 tried treatment methods. What is revealing is that these methods can be adapted to meet the requirements of a group of women whose complaints and concerns might otherwise be considered a function of their time of life or a consequente of intransigent psychosocial problems and which are consequently not amenable to therapeutic intervention. However, it must be emphasised that for these women psychological treatment is seen as a complement to hormonal treatment and not as a substitute. Indeed, gynaecological examination and appropriate hormonal treatment constitute an essential first step before any form of psychological treatment should be embarked upon.
References 1 Utian WH. The mental tonic effect of oestrogen administered to oophorectomised females. Sth Afr Med J 1972; 46: 1079-1082. 2 Campbell S, Whitehead M. Oestrogen therapy and the menopausal syndrome. Clin Obstet Gynecol 1977; 4: 31-47. 3 Demrerstein L, Burrows GD, Hyman GJ, Sharpe K. Hormone therapy and affect. Maturitas 1979; 1: 247-259. 4 Brugha T. Bebbington P, Tennant C, Hurry J. The list of threatening life experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985; 15: 189-194.
48 5 Aitken RCB. Measurement of feelings using visual analogue scales. Proc R. Sec Med 1969; 62: 989-993. 6 Greene JG. A factor analytic study of climacteric symptoms. J Psychosom Res 1976; 20: 425-430. 7 International Health Foundation. The mature woman: a fiist analysis of a psychosocial study of chronological age and menstrual ageing. Geneva: IHF, 1975. 8 SarreII PM, Whitehead MI. Sex and menopause: defining the issues. Maturitas 1985; 7: 217-224. 9 Greene JG. Bereavement and social support at the climacteric. Maturitas 1983; 5: 115-124. 10 Ballinger S. Psychosocial stress and symptoms of menopause: a comparative study of menopause clinic patients and non-patients. Maturitas 1985; 7: 315-327. 11 Greene JG. The social and psychological origins of the climacteric syndrome. Aldershot (Hants) and Brookfield (Vermont): Gower, 1984. 12 Silver RL., Wortman CB. Coping with undesirable Iife events. In: Garber J, SeIigman MEP, (eds). Human helplessness: theory and applications. New York: Academie Press, 1981. 13 Stem R. Behavioural techniques: a therapist’s manual London: Academie Press, 1978. 14 Garfield SL, Bergin AE. Handbook of psychotherapy and behaviour change. New York: Wiley, 1978.
41
Elsevier MAT 00426
Evaluation of a psychological treatment programme f or climacteric women J.G. Greene 1 and D.M. Hart 2 ’Department of Clinical Psychologv, Gartnavel Royal Hospital, and ’ Department of Gynaecology, Stobhill General Hospita1 Glasgow, U.K.
(Received 5 March 1986; version received 9 June 1986; accepted 10 December 1986)
A psychological assessment and treatment programme designed for a group of climacteric women with severe and varied psychological complaints and symptoms is described and evaluated. Ah the women were currently experiencing stressful psychosocial difficulties within their life situation. The treatment programme comprised an educational, a counselling and a behavioural component. By the end of the sixth session of therapy, most women showed a significant improvement in their main complaint, accompanied by improvements in general symptoms and personal adjustment. Two-thirds considered that they had benefited substantially from treatment. The outcome of the treatment was considered to be encouraging in what might otherwise be considered a potentially unresponsive group of women.
(Key words: Behaviour therapy; Counselling; Menopause; Psychotherapy)
Introduction
Many women attending menopause clinics for treatment of vasomotor symptoms and other climacteric problems also present with a variety of psychological symptoms and complaints. Hormone replacement therapy (HRT) is generally effective in bringing about relief of vasomotor symptoms, frequently accompanied by a feeling of general well-being [l] and the alleviation of psychological symptoms [2,3]. There remains, however, a group of women in whom HRT relieves the vasomotor symptoms, but has little effect on the other complaints. These women may require and benefit from more psychologically based treatments. This paper describes an assessment and treatment programme for such a group of women referred to a department of clinical psychology from a menopause clinic and evaluates the treatment outcome. Correspondence to: Dr. J.G. Greene, Department of Clinical Psychology, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G120XH, Scotland, U.K.
0378-5122/87/%03.50 0 1987 Elsevier Scientific Publishers Ireland, Ltd.
42
Subjects and methods
Subjects These were 24 climacteric women, who were admitted successively into tl treatment programme. Al1 were currently attending a menopause clinic to whic they had been referred for treatment of vasomotor symptoms. Five women we peri-menopausal, (last menstruation between 3 and 12 mth previously, and 19 we post-menopausal (no menstruation within the past year). Hormonal treatment hz relieved vasomotor symptoms in these women to such an extent that none was ar longer greatly bothered by them. However, they were referred to a psychologi because of persistent symptoms and complaints thought to be of psychogenic origi The onset of these complaints had occurred in al1 cases after the age of 40 durit the climacteric years, al1 of the subjects dating the onset to within 2 yr of referr; Assessment At the first appointment, the details and history of the main presenting cor plaint and information about personal and family circumstances as wel1 as al ongoing or long-standing sources of stress or worry were obtained by means of semi-structured interview. This was akin to a standard psychological interview. Li events of onset within the previous year were elicited using the List of Threatenil Life Experiences [4], this being a list of the 12 event categories which account for t great majority of distressing life events. In order to assess the outcome, the main presenting symptom was quantified 1 having the women rate how severe or disturbing it was by means of a lO-cm visu analogue scale [5], the end-points being labelled ‘not at all’ and ‘extremely’. T results were supplemented by the scores recorded on two other scales. One of the was the 18-item Climacteric Symptom Rating Scale developed by the author [ This yields 2 separate summed measures, one of 11 psychological symptoms (cryi spells, attacks of panic, worrying needlessly, etc.) and the other of 7 soma symptoms (rheumatic pains, dizzy spells, etc.) commonly reported by climacte women. The other was the IHF Index of Subjective Adaptation. This measures woman’s satisfaction with her daily life, health and future prospects. It was US because it seemed appropriate to some of the concerns these women voiced and 1: been shown to be a sensitive measure of climacteric response [7]. At the end of the first interview a case formulation was arrived at and tl formed the basis of the treatment approach for subsequent sessions. Al1 assessme and treatment was carried out by a clinical psychologist. Results
Main presenting complaints These were elicited in response to an open-ended question as to what constitui the main problem. A breakdown is given in Table 1; this does not exclude otl complaints, but indicates those spontaneously reported by the women as the mc
43 TABLE PATIENT
1 CHARACTERISTICS
Numbers treated Mean age Marital status Married Widowed Single Presenting complaint Anxiety/agitation Depressed/lethargic Psychosomatic symptom Sexual dysfunction Symptom rating scale Psychological (norm) Somatic (norm) Subjective adaptation Index (norm) Long-standing problems Husband’s illness Marital discord Children Elderly parents Recent life events Deaths Serious family illness Serious family discord
24 49 (range 42-55) 21 2 1 13 5 3 3 22.5 (11.8) 9.3 ( 4.9) 29.7 (18.3) 5 4 4 3 8 3 3
distressing. For example, in line with the findings of Sarrel and Whitehead [8] sexual complaints were common, but for the most part did not constitute serious sexual dysfunction. Only 3 women saw them as the major problem for which they wanted help and in al1 3 this entailed loss of desire. They were seen by the other women as less significant, or relatively so, in comparison with other complaints. Anxiety complaints consisted of a rnixture of generalised anxiety, transient panic attacks and situational phobias, most of which had an agoraphobic element. Depressive complaints consisted mainly of loss of energy and interest, and were reactive in nature, rather than endogenous. Psychosomatic symptoms included one case of recurrent chest pains, one of low back pain and one of recurring headaches. Eleven women were receiving tranquillisers from their genera1 practitioner, without much symptomatic relief, but only 2 had a history of psychiatrie treatment. It is important to reiterate that in al1 these women the onset of the presenting complaint had occurred during the climacteric years. These complaints were taken as the primary treatment targets and the main criteria for evaluating outcome. Climacteric
symptom
rating scale
As can be seen from Table 1, the mean scores for both psychological and somatic symptoms were higher than those in a genera1 population of Scottish climacteric women [9], indicating widespread genera1 symptoms.
44
Subjective adaptation
Compared with that in a genera1 population of Swiss menopausal women [7] this score was also high, indicating overall poor adaptation and dissatisfaction with mid-life status. Both this and the symptom scale were later used to assess the general outcome. Ongoing and long-standing problems
These were fairly common, and a total of 15 women had problems of this type, al1 associated with family members, which had been ongoing for some years prior to referral. One woman had 2 problems which fell into this category. A breakdown of these is shown in Table 1. In 3 cases the husband’s illness prevented him from working, thereby causing secondary financial worries. In 2 of the cases of marital discord, the husband’s alcoholism was playing a significant part. The problems connected with children comprised 2 where there was a chronic medical condition and 2 where there was marked social discord with the parents. In the case of elderly parents, the problems involved either a physical or mental disability, necessitating their being cared for by the family. Life events of recent onset
In all, 10 women reported one major, threatening life event occurring within the year prior to referral to the menopause clinic and a further 2 reported two such events. The 3 categories into which these 14 events fa11 are shown in Table 1. The deaths and ilhress had occurred mostly in the older generation, which is consistent with what was found in a general population of climacteric women [9], but the serieus family problems involved children in two cases. It should be noted that these were not the same as long-standing problems in that they were of recent onset and their impact is therefore considered to be quite different [lol. In general, from the symptomatic point of view, this was a fairly disturbed group of women, each of whom had at least one long-standing family problem or had experienced a recent stressful life event. Treatment programme
The broad treatment rationale was that the symptoms and complaints reported by these women were, in part at least, an expression of or a reaction to their current psychosocial problems. However, many of the problems had begun before the climacteric, although the symptoms and complaints had had their onset only during that time. The aetiological model adopted was that, during the climacteric, women become more vulnerable to the effects of psychosocial difficulties with which they might have been better able to cape at an earlier age. This model was based on the findings of a previous study in which it was found that climacteric women were less
45
able than pre-climacteric women to cape with adverse life events [9]. In this model, which is more fully described elsewhere [ll], vulnerability is considered to be both physical and psychological in nature, giving rise to both types of symptoms. This model shaped the treatment programme which had grown out of the therapist’s experience over a number of years in assessing and treating climacteric women with psychological problems. The therapy incorporates many of the standard and established methods of psychological treatment, modified or adapted to the particular needs of the climacteric woman. It is a pragmatic approach and has 3 major components, i.e., an educational, a counselling and a behavioural component. Educational
component
This component was aimed at giving women some understanding of the role played by psychosocial factors in their condition. Many tended to attribute al1 their symptoms to the menopause and were perplexed by the fact that although HRT had greatly helped their vasomotor symptoms, it had not relieved them of the others. In effect, the model referred to above was explained to them in the context of their own particular problems. This was found to be a necessary stage before proceeding further. Counselling
component
This consisted of discussing and advising women about their current problems and concerns. It included the exploration of feelings and attitudes, particularly those of women with low subjective adaptation. Where appropriate, bereavement counselling was used. This component is not a psychotherapeutic procedure as such, but more of a problem-solving exercise aimed at working out solutions and developing coping skills [12]. Behavioural
component
The object here was symptomatic treatment using standard behavioural techniques [13] such as anxiety management, desensitisation for phobic problems, and cognitive therapy for depressive symptoms. These included the use of relaxation tapes, diaries and home exercises as necessary. After the initial assessment women were seen at 3-4 week intervals for between 45-60 min. In practice, each session included elements of al1 3 components although, as indicated above, the educational aspect tended to be dealt with in the earlier sessions. Outcome of treatment
To evaluate the outcome, al1 the women were assessed at the end of the sixth session of treatment. Evaluation was carried out at this point in order to standardise the amount of treatment provided and because experience had shown that if progress had not been made with this type of treatment by this time, a satisfactory
46 TABLE
11
MEAN
SCORES
ON OUTCOME
MEASURES
BEFORE
AND AFTER
Means Pre
Post
Differente
8.6 22.5 9.3 29.7
4.1 14.2 6.7 21.1
4.5 8.3 2.6 8.6
TREATMENT t
P
5.92 3.32 2.10 2.50
< < < <
+SE Main presenting complaint Psychological symptoms Somatic symptoms Subjective adaptation r = paired
f f i: f
0.76 2.50 1.24 3.44
0.001 0.01 0.05 0.02
t-test value
outcome was unlikely. Nevertheless, several women continued to be seen beyond this point. Al1 the women again rated their main presenting symptom on the visual analogue scale. They also completed the Symptom Rating Scale and the Index of Subjective Adaptation and made a rating of their overall improvement over the treatment period. The results of this re-assessment are shown in Table 11. The results were analysed by the paired t-test. It can be seen that there was a highly significant decrease in the mean severity rating of the main complaint. There was also a significant reduction in general symptoms, especially psychological symptoms, and an improvement in subjective adaptation. In the overall improvement rating, 7 women rated themselves as considerably improved, 9 as much improved, 4 as moderately to slightly improved, 3 as unchanged and 1 as worse. In all, therefore, some two-thirds of the women thought that they had benefited substantially from treatment. There was, however, clear evidente that the response depended on the nature of the main complaint. Those with anxiety as a major element in their condition improved most, followed by those with depressive complaints. Women with psychosomatic complaints or loss of libido as the main presenting complaint showed little or no response to treatment. Of the 3 women with loss of sexual desire as a main complaint, 1 showed a slight improvement while 2 remained unchanged. In the case of the 3 with psychosomatic symptoms, 1 showed moderate improvement. 1 remained unchanged and 1 became worse over the treatment period. It is noteworthy (Table 11) that somatic symptoms showed the least statistically significant improvement.
Discussion
The psychological treatment package provided to this group of fairly disturbed climacteric women seems to have been reasonably successful in alleviating the main complaint in most cases. This improvement was accompanied by a reduction in general symptoms and, for some, it also seems to have resulted in their feeling less dissatisfied with their mid-life state. Not all the women showed the same degree of improvement, since certain complaints, notably psychosomatic and sexual ones,
47
were less responsive to therapy. However, this is not an unusual finding in regard to these latter complaints, which are notoriously resistant to psychotherapeutic approaches [14]. In the present study it was felt that the greater improvement in complaints with an anxiety or depressive element was due to the fact that these are also more amenable to a behavioural approach. This is not to say that the educational and counselling components did not contribute to the outcome. If it is accepted that psychosocial problems play a part in the aetiology of the complaints suffered by such women, then attaining insight into and a balanced perspective on these problems is a necessary first step towards remedying the symptomatic effects. Nevertheless, despite this insight, symptoms may sometimes persist and require to be treated by more direct behavioural or possibly pharmacological means. The weakness of an evaluative study of this kind is that, in the absente of a control group, it is not possible to state categorically the extent to which an improvement is a function of therapy rather than of other factors-although it is difficult to see how it would be possible to contrive a control group that could provide a convincing answer to that question. What can be said is that al1 the women had experienced persistent psychological complaints extending over a period of time prior to treatment and that none had shown the characteristic improvement in mental well-being associated with HRT and the relief of vasomotor symptoms. Nor had any shown much response to minor tranquillisers. Furthermore, it was the therapist’s observation over the treatment period that women who benefited were responding actively to the different treatment components in the anticipated way. Finally, the efficacy of such treatments, both short and long-term, has been repeatedly demonstrated with other types of patients [14]. Perhaps, therefore, it should come as no surprise that a generally satisfactory outcome should be achieved using what are in fact wel1 tried treatment methods. What is revealing is that these methods can be adapted to meet the requirements of a group of women whose complaints and concerns might otherwise be considered a function of their time of life or a consequente of intransigent psychosocial problems and which are consequently not amenable to therapeutic intervention. However, it must be emphasised that for these women psychological treatment is seen as a complement to hormonal treatment and not as a substitute. Indeed, gynaecological examination and appropriate hormonal treatment constitute an essential first step before any form of psychological treatment should be embarked upon.
References 1 Utian WH. The mental tonic effect of oestrogen administered to oophorectomised females. Sth Afr Med J 1972; 46: 1079-1082. 2 Campbell S, Whitehead M. Oestrogen therapy and the menopausal syndrome. Clin Obstet Gynecol 1977; 4: 31-47. 3 Demrerstein L, Burrows GD, Hyman GJ, Sharpe K. Hormone therapy and affect. Maturitas 1979; 1: 247-259. 4 Brugha T. Bebbington P, Tennant C, Hurry J. The list of threatening life experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985; 15: 189-194.
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